INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on September 1, 2026 through September 2, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Williamsport Family Medical Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
|
Observations
Based on a review of administrative documents, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.
The last documented sign-off from the project director was dated January 15, 2025, and the next one was due no later than January 15, 2026; however, the documentation provided was dated August 11, 2026, and signed by the compliance specialist. When the document was reviewed with the project director, their signature was also added on to the document.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Williamsport Family Medical Center Facility Director will review the nature and background for the need of annual update and the need of sign-off of the written manual delineating project policies and procedures in upcoming 10/6/26 Staff Meeting and Clinical Supervisor reviewed in 9/23/26 clinical meeting.
The Project Director will review and ensure policies are updated and issue a signed attestation to that effect by January 15, 2027. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one of eight client records reviewed.
Client # 6 was admitted on December 18, 2025, and was discharged on August 24, 2026. A release of information form for funding source signed by the client on December 18, 2025, did not specify the specific information to be disclosed.
The findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Clinical supervisor met with team on 9/16/26 to review the citation and the requirement that written informed and voluntary consent for disclosure of information include the specific information to be disclosed. Staff are educated on proper completion of review of releases for information prior disclosure.
Monthly chart audits will be completed by quality and clinical supervisor to ensure release of information forms are completed appropriately and contain the specific information to be disclosed. Findings will be reviewed with staff as needed. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
|
Observations
Based on a review of patient records, the program failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in one applicable patient records reviewed.
Patient #6 transferred from another narcotic treatment program and was admitted on December 18, 2025. Patient #6 was later discharged on August 24, 2026. There was no documentation indicating that the program notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
These findings were reviewed with program staff during the licensing process.
|
Plan of Correction
Staff reviewed the requirements of 715.20(4) during the staff meeting on 9/16/26. Staff were reminded that for patients transferring from another narcotic treatment program, the patient record must document notification to the transferring program of the patient's admission and the data the patient's initial dose.
Monthly chart reviews will be completed to ensure required transfer documentation is present and completed. Any identified deficiencies will be addressed promptly |